Title: Miss / Ms / Mrs / Mr / Other _______ (please circle)

Forename: _____________________ Surname: ______________________

Address:

Postcode: _______________________

Email: __________________________________________________________

Home Tel: _______________________ Mobile: ______________________

N.I. Number: ________________________

Do you require a work permit to work in the UK? Yes □ No □

If Yes, do you have a valid work permit? Yes □ No □

Expiry date of work permit _____________________

Do you have any criminal convictions which are not “spent” under the Rehabilitation of Offenders Act 1974? Yes □ No □

If Yes please provide details ___________________________________________________

If an offer of employment is made to you, this will be subject to the receipt of satisfactory references to cover the last 5 years.

These references must be received by us before you can join Allianz Insurance.

To progress your application for employment with Allianz Insurance, you must supply full details of your work history over the last five years.

If you were employed by an employment agency please give the name and telephone number of the agency.

For periods of study, please supply details of the school/college/university attended.

If there are any gaps in employment please include these on the form with from and to dates and the reason for the gap

If you choose to offer me a role:

You may contact my previous employers immediately

I do not wish you to contact my current employer

Date which you can contact my current employer ____________________

Please provide us with 5 years of references, starting with your most recent employer/college/school.

Date From | Date To | Employer/College/School/Gap | Job Title/Grades/Gap reason | Reason for leaving | Name &